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Division of
Professional Regulation

Statement of Complaint



INSTRUCTIONS

This form is for the use of persons who wish to file a complaint with the Division of Professional Regulation against a professional licensee, registrant or certificate holder or against a person/business practicing or operating without the required professional license.

If you are a Delaware-licensed healthcare provider or other entity that is required to report a healthcare provider under your mandatory duty to report, please submit the Report of Healthcare Provider instead of this form. If you need to report child abuse or neglect, see Mandatory Reports of Child Abuse or Neglect on the Division’s website.

In order for the Division to start an investigation of possible violation of Delaware licensing, registration or certification laws and regulations, you must complete this online form. Be sure to submit any documents you may have to support your complaint by faxing them to (302) 739-2711, or email them to investigations.dpr@state.de.us. Delaware law allows the Division to keep the name of the person who files a complaint confidential, when appropriate.

Fields marked with ** are required by law in order to accept your complaint. Your complaint may be rejected if you leave any portion of a required field blank.

If you need help completing this form, call (302) 744-4500 and ask to speak to an investigator.



 

 

TYPE(S) OF COMPLAINT:


 

COMPLAINANT INFORMATION

A. Your Information


B. Your Attorney, If Any


 

SUBJECT OF COMPLAINT INFORMATION

C. Person About Whom You Are Complaining


D. Business Involved, If Any


 

WITNESS INFORMATION

E. Name/Address of Witness, If Any

F. Name/Address of Second Witness, If Any

 

Note: If additional witnesses are available, list their names, addresses any other pertinent data in a manner similar to above on a separate email sent to investigations.dpr@state.de.us.

 



 

H. Description of Complaint**

Please describe your complaint in detail below. List services provided by the licensee, registrant, certificate holder or individual. Include the dates, times and locations where you believe offenses occurred and the nature of your complaint. To the best of your ability, outline how you believe the subject of your complaint has committed unprofessional conduct, unlicensed activity, or other violation. If applicable, you may submit documents in support of your complaint by faxing them to the Investigative Unit at (302) 739-2711 or email them to investigations.dpr@state.de.us.
 


 

For more information on the investigative process or to view the laws, rules and regulations of a specific board or commission, please visit the Division of Professional Regulation’s website at dpr.delaware.gov.
 

Send Copy of Complaint to your Email Address:



 

    


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